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Evidence case study: reviewing the evidence for clinical effectiveness of patella resurfacing with total knee replacement

What was the aim of the evidence review?

The aim was to review the evidence for carrying out patella resurfacing with total knee replacements (TKR), to inform a commissioning policy review for this procedure.

What did they do?

Belinda Alexander, Senior Commissioning Manager at Bath & North East Somerset Clinical Commissioning Group (CCG) requested a search from Royal United Hospital Bath NHS Foundation Trust library service. This included Google Scholar and healthcare databases including Medline, EMBASE, CINAHL, PsychINFO, Health Business Elite and Cochrane. The Royal College of Surgeons policy team were also contacted for their views, as well as the National Institute of Health and Care Excellence (NICE) who were asked directly as the guidance wasn’t very clear.

How long did it take?

About 40 hours over two weeks, including contacting NICE and other organisations.

What did they find?

There are numerous papers assessing the evidence for the effectiveness of this procedure, but the available systematic reviews indicate that there is no significant benefit to routine resurfacing of the patella, either with patient satisfaction or functional status. Most of the systematic reviews also report no difference between the groups in the incidence of post-operative anterior knee pain.

In April 2015, the American Academy of Orthopaedic Surgeons published an evidence-based clinical practice guideline on the surgical management of osteoarthritis. They concluded that “Strong evidence supports no difference in pain or function with or without patella resurfacing in total knee arthroplasty”.

Who was the evidence shared with and why?

The evidence was shared with the CCG Joint Commissioning Committee which includes Local Authority and Public Health representatives. This was to seek approval to change the commissioning policy. It was also shared with GPs through the monthly GP forum meetings, for both educational purposes but also approval to restrict providers carrying out the procedure unless as an ‘individual funding request’. It was also shared with providers (managers and clinicians) to give them advance warning of the change in policy.

How were the findings used in local decision-making?

The CCG executive team and Joint Commissioning Committee approved changing the commissioning policies to ‘prior approval’ and we have incorporated this within our contracts with local providers. If procedures are carried out without approval, the CCG will not pay the provider.

What has changed as a result?

Bath & North East Somerset CCG has changed patella resurfacing with total knee replacement to become a ‘prior approval’ procedure. Patella resurfacing leads to an increase in the cost of total knee replacement of approximately £3,000 per patient.

In 2015/16, 134 of these procedures have been identified giving a potential full year saving of approximately £400,000.